The Two Types of Bipolar Disorder

The DSM-IV (the diagnostic Bible) divides bipolar disorder into two types, rather unimaginatively labeled bipolar I and bipolar II. “Raging” and “Swinging” are far more apt:

Bipolar I

Raging bipolar (I) is characterized by at least one full-blown manic episode lasting at least one week or any duration if hospitalization is required. This may include inflated self-esteem or grandiosity, decreased need for sleep, being more talkative than usual, flight of ideas, distractibility, increase in goal-oriented activity and excessive involvement in risky activities.

The symptoms are severe enough to disrupt the patient’s ability to work and socialize, and may require hospitalization to prevent harm to themselves or others. The patient may lose touch with reality to the point of being psychotic.

The other option for raging bipolar is at least one “mixed” episode on the part of the patient. The DSM-IV is uncharacteristically vague as to what constitutes mixed, an accurate reflection of the confusion within the psychiatric profession. More tellingly, a mixed episode is almost impossible to explain to the public. One is literally “up” and “down” at the same time.

The pioneering German psychiatrist Emil Kraepelin around the turn of the twentieth century divided mania into four classes, including hypomania, acute mania, delusional or psychotic mania, and depressive or anxious mania (ie mixed). Researchers at Duke University, following a study of 327 bipolar inpatients, have refined this to five categories:

Pure Type 2 (24.5 of sample), by contrast, is a very severe form of classic mania, similar to Kraepelin’s acute mania with prominent euphoria, irritability, volatility, sexual drive, grandiosity and high levels of psychosis, paranoia, and aggression.

Group 3 (18 percent) had high ratings of psychosis, paranoia, delusional grandiosity and delusional lack of insight; but, lower levels of psychomotor and hedonic activation than the first two types. Resembling Kraepelin’s delusional mania, patients also had low ratings of dysphoria.

Group 4 (21.4 percent) had the highest ratings of dysphoria and the lowest of hedonic activation. Corresponding with Kraepelin’s depressive or anxious mania, these patients were marked by prominent depressed mood, anxiety, suicidal ideation and feelings of guilt, along with high levels of irritability, aggression, psychosis and paranoid thinking.

Group 5 patients (15.6 percent) also had notable dysphoric features (though not of suicidality or guilt) as well as Type 2 euphoria. Though this category was not formalized by Kraepelin, he acknowledged that “the doctrine of mixed states is … too incomplete for a more thorough characterization …”

The study notes that while Groups 4 and 5 comprised 37 percent of all manic episodes in their sample, only 13 percent of the subjects met DSM criteria for a mixed bipolar episode; and of these, 86 percent fell into Group 4, leading the authors to conclude that the DSM criteria for a mixed episode is too restrictive.

Different manias often demand different medications. Lithium, for example, is effective for classic mania while Depakote is the treatment of choice for mixed mania.

The next DSM is likely to expand on mania. In a grand rounds lecture delivered at UCLA in March 2003, Susan McElroy MD of the University of Cincinnati outlined her four “domains” of mania, namely:

As well as the “classic” DSM-IV symptoms (eg euphoria and grandiosity), there are also “psychotic” symptoms, with “all the psychotic symptoms in schizophrenia also in mania.” Then there is “negative mood and behavior,” including depression, anxiety, irritability, violence, or suicide. Finally, there are “cognitive symptoms,” such as racing thoughts, distractibility, disorganization, and inattentiveness. Unfortunately, “if you have thought disorder problems, you get all sorts of points for schizophrenia, but not for mania unless there are racing thoughts and distractibility.”

Kay Jamison in Touched with Fire writes:

“The illness encompasses the extremes of human experience. Thinking can range from florid psychosis, or ‘madness,’ to patterns of unusually clear, fast, and creative associations, to retardation so profound that no meaningful activity can occur.”

The DSM-IV has given delusional or psychotic mania its own separate diagnosis as schizoaffective disorder – a sort of hybrid between bipolar disorder and schizophrenia, but this may be a completely artificial distinction. These days, psychiatrists are acknowledging psychotic features as part of the illness, and are finding the newer generation of antipsychotics such as Zyprexa effective in treating mania. As Terrance Ketter MD of Yale told the 2001 National Depressive and Manic Depressive Association Conference, it may be inappropriate to have a discrete cut between the two disorders when both may represent part of a spectrum.

At the 2003 Fifth International Conference on Bipolar Disorder, Gary Sachs MD of Harvard and principal investigator of the NIMH-funded STEP-BD reported that of the first 500 patients in the study, 52.8 percent of bipolar I patients and 46.1 percent of bipolar II patients had a co-occurring (comorbid) anxiety disorder. Dr. Sachs suggested that in light of these numbers, comorbid may be a misnomer, that anxiety could actually be a manifestation of bipolar. About 60 percent of bipolar patients with a current anxiety disorder had attempted suicide as opposed to 30 percent with no anxiety. Among those with PTSD, more than 70 percent had attempted suicide.

Depression is not a necessary component of raging bipolar, though it is strongly implied that what goes up must come down. The DSM-IV subdivides bipolar I into those presenting with a single manic episode with no past major depression, and those who have had a past major depression (corresponding to the DSM -IV for unipolar depression).